What Do the Midterm Election Results Mean for Health Care and People Living With HIV?

Unless you've been living under a rock the past few days, you have heard that Democrats took back the U.S. House of Representatives on Tuesday, Nov. 6, as well as several state governorships and legislatures -- even as Republicans held the U.S. Senate. And President Trump both said that he was willing to work with Dems on some issues and threatened them not to try any funny stuff regarding investigations of him.

Mark Hannay: First and foremost, it means that the Affordable Care Act [ACA, aka Obamacare] is here to stay, because we no longer have two chambers of Congress trying to kill it. In fact, it was the House that really wanted to kill it, with far less enthusiasm from the Senate. The Trump Administration is still going to try to do whatever they can to sabotage it. They already have, by letting states let insurers offer sub-par plans that may not offer all the benefits required by the ACA or that may discriminate against certain patients. But overall, ACA is safe for now.

The other big outcome of the elections is the strong public support shown for Medicaid, even in red states, with Utah, Nebraska, and Idaho all passing ballot measures supporting Medicaid expansion in their states. The governor and legislatures of those states will have to move forward to implement that. And several states now have either a Democratic governor and/or legislatures, which overall creates a more favorable environment for ACA Medicaid expansion, which about a third of states still do not have.

Also off the table in Congress are Medicaid block-granting, Medicare privatization, and wholesale cuts to Planned Parenthood, which is a major provider of both HIV primary care and general sexual health services.

TM: Good stuff, yes? What about with HIV-specific programs like the AIDS Drug Assistance Program (ADAP), Ryan White CARE Act, or Housing Opportunities for People With AIDS (HOPWA)?

MH: There's nothing new that I'm aware of. They're fine for now. On another note, both Nancy Pelosi in the House and Mitch McConnell in the Senate have said they want to do something about reining in prescription drug prices. People on both sides of the aisle are really angry about that and want to see something done. But you have to beat Big Pharma! I think we'll see steps in that direction but don't know whether they'll really take on the status quo or just nibble around the edges. Maybe we'll see them push forward bills demanding transparency from drugmakers justifying why prices are so high. Maybe we'll see moves to allow individual consumers to purchase drugs outside the country, particularly from Canada. Certainly, we'll see moves to allow Medicare to negotiate drug prices, which the current law does not allow for. We may see moves to set industry standards for pharmaceutical benefits managers [PBMs], which are like HMOs for drugs and are currently completely unregulated.

TM: A lot of us put activism into these elections. Where should we put our activism now?

MH: It depends on what the new House puts on the table and whether those are things we want to get behind, such as improvements to the ACA, like how to make coverage more affordable. In many states, there's no significant or meaningful oversight of premium increases year to year. Here in New York and some other states, insurers must submit and justify their increase proposals to the state, which may modify the increase. But about two-thirds of states use the federal marketplace, which doesn't have much of an oversight process. If you really want to follow the blow-by-blow in D.C. on health care, I suggest subscribing to the digests of both Kaiser Health News and Politico Pulse. You could also follow on Twitter the national advocacy groups Families USA and Community Catalyst. But a lot of health policy is state by state, so you should try to find a state group or ask your local AIDS agency what state advocacy group they ally with.

TM: So, overall, can we relax now?

MH: Hmmm ... some! We have to keep our eyes on a federal court case in Texas where several state attorneys general and a few governors have claimed that the ACA is now unconstitutional because last year's tax law eliminated the ACA's individual mandate clause. But other attorneys general say that's not the case. The judge in the case is notoriously conservative, and people have been expecting an initial ruling for some time now. I think the judge was waiting to see how the elections went. So should that case move forward, it will at some point likely end up before the Supreme Court.

The other thing we have to watch state by state are new requirements being imposed by the Trump administration on Medicaid -- work requirements, having to pay premiums, drug tests, or so-called "lock-out periods" in which people are not eligible to sign up. The National Health Law Program is tracking that. That would particularly affect the coverage of people on Medicaid under ACA expansion who are termed "able-bodied adults." People with HIV may or may not have a disability determination from Social Security, so this could become an issue at some point for those on Medicaid or aiming to qualify for it.

TM: Do you think it's silly to talk about universal health coverage at this point?

MH: No. There will still be concerted national and state-level efforts to move forward universal health coverage bills, particularly single-payer-style bills. I think those efforts should be supported, even if they're not likely in the near term because the Trump administration has said they'll approve no waivers for such programs at the state level. But it still keeps the drumbeat out there, creates the space for shorter-term stuff to get done, and lays a foundation for moving toward such programs down the road.

TM: Cool stuff, Mark. Thanks!

MH: Thank you.

Tim Murphy has been living with HIV since 2000 and writing about HIV activism, science and treatment since 1994. He writes for and has been a staffer at POZ, and writes for the New York Times, New York Magazine, Out Magazine, The Advocate, Details and many other publications. He is also the author of the NYC AIDS-era novel Christodora.

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